1. Dr Anil Jain MS, FRCS
Professor of Orthopaedics
University College of Medical
Sciences,
Delhi
&
Editor
Indian Journal of
Orthopaedics

2. Definition
 extention contracture of the knee
 due to extrarticular, intraarticular or combined
pathology.
 Clinically it is often difficult to differntiate between
predominantly intraarticular or extraarticular
component
 Extrarticular pathology -due to quadriceps scarring,
the affected knee has some degree of flexion possible
when the hip is flexed
 and roentgenograms reveal an apparently normal
joint space

3. Anatomy of knee stiffness
 Between full flexion to full extension- patella travels
-9 cms (3.5 inches)
 This is the excursion of RF
 4 ways to block flexion
 All prevent distal excursion of patella during flexion

4. Causes of blocking
 Fibrosis of VI – ties deep surface of RF to the
front of femur in suprapatellar pouch and
above.
 Adhesions of deep surface of patella to the
femoral condyle
 Fibrosis and shortening of lateral expansion
of vasti and their adherence to lateral aspect
of femoral condyle.
 Actual shortening of RF

5.  Clinically
 difficult to differntiate----
 predominantly intraarticular or extraarticular
component.
 Only extrarticular due to quadriceps scarring,
 knee has some degree of flexion possible when the
hip is flexed
 roentgenograms even may reveal an apparently
normal joint space.

6. Causes
 most commonly after fracture of thigh
 intraarticular fracture of the distal femur.
 Other causes of knee contracture –
 Post total knee arthroplasty
 Immobilization of knee for a period of 8 weeks
or more,
 Arthogryposis;
 Cerebral palsy,
 Poliomyelitis,
 Spina bifida,
 Haemophilia

7. Post traumatic knee stiffness
 Femoral shaft fracture – NU,DU, normal union
 Fracture femoral condyle
 Fracture dislocation of knee
 Fracture of tibial plateau
 Contracture of knee may occur with the knee in
complete extension, in flexion alone, or in flexion,
external rotation, and valgus position,

8. Knee contrcture in extension
 commonly occurs -----
 fracture of femur
 or extensive soft tissue damage of anterior aspect
of thigh,
 scarring or fibrosis of all or part of the quadriceps
mechanism,
 chronic osteomyelitis of femur/sequale of septic
arthritis of knee.
 following total knee replacement,

9. Some issues -Indications
 Which knee to be operated-
 Any pt with total range of 70 degree will be happy
 This 70 degree in functional arc ( 20-90) would be
better than 50-120
 Career specific range

10. Some issues–when to intervene
 Sufficient time has elapsed from initial event and no
further improvement is occuring with physiotherapy
 And
 Will not improve without operation.

11. Some issues- expectations
 If a pt gains 0-90 degree – it is a good outcome of
surgery
 Predictors of outcome-
 Preoperative ROM
 Intraoperative gains in ROM
 Good postoperative mobilization programme.

12. Treatment
 Prevention – mobilize knee early
 Stiff knee – no improvement by physical
therapy
 surgery indicated.
 Various techniques ----
 gentle manipulation under anaesthesia,
 quadricepsplasty,
 quadricepsplasty by limited approach,
 quadricepsplasty with mini-incision and
arthroscopic.

13. Manipulation
 contraindicated if any pathologic process-
 an inflammed joint following early injury or
operation
 Caution- severe osteoporosis sudden, vigorous
manipulation may lead to fractures around knee.
 successful manipulation - if the patella is
relatively mobile,
 no fibrosis in suprapatellar region
 the resistance is elastic.
 does not work in an old contracture.

14. Manipulation
 Manipulation useful following total knee
replacement.
 under GA with full muscle relaxation.
 No Undue force
 can feel adhesion separating and ROM
improving.
 Post manipulation -------
 the knee in fully flexed position.
 Ice –bags
 Immediate supervised active exercises .

15. Quadriceplasty:
 a surgical procedure to the quadriceps muscle
 Thompson
 Judet.
 success depends on;
 If rectus femoris muscle has escaped injury.
 How well the rectus femoris muscle can be
isolated from the scarred parts of the
quadriceps mechanism.
 How well the muscle can be developed by
active use. Success on post surgery PT

16. Thompson quadriceplasty:
 Thompson (1944).
 RF freed completely from rest of the quadriceps
 vastus intermedius - if scarred - excise
 aponeurotic expansion of other vasti are divided on
either side of patella.

17. Surgical procedure
 Incision-
 anterior incision from proximal one third thigh to
patella .
 Exact location depends on position of scars.
 The medial and lateral para patellar two incisions
approach by Hahn et al.
 The deep fascia is divided in line with skin incision.

18. Surgical procedure:-
 rectus femoris muscle separated to full extent
 separated from VM and VL.
 anterior capsule of knee joint including the
lateral expansions of vasti on both side of patella
are divided far enough to overcome their
contracture.
 vastus intermedius is completely excised,
 rectus femoris if destroyed - creat a new from
ant. scar

19. Surgical procedure:-
 knee is slowly flexed to 110 degree
 remaining intrarticular adhesions are released.
 If the flexion still does not improve
 RF tendon is to be lengthened
 should be avoided as best as possible
 Subcutaneous tissue and fat is interposed
between VM ,VL and rectus. If these muscles are
relatively normal, these are sutured to rectus as
far distally as the distal third of thigh.

20. Key issues
 Not to use tourniquet
 If used achieve satisfactory hemostasis
 Hematoma delays the progress
 Aftercare ----
 Put knee on pearson knee attachment – that will
allow gravity assisted flexion and passive extention
 Or CPM
 More vigrous physiotherapy will give better outcome.
 May require manipulation

21. Problems and obstacles
 Scar problem – delays recovery –incision
 Infection ????
 Extention lag – most common complication,
 10 deg in 67% cases – Moore et.al. ( J trauma 1987)
 18 deg in 33% cases – Pick RY . ( Clin Ortho 1976)
 Usually 20 degree or more in immediate post op
period
 Regains in one year – if RF is intact
 If RF damaged – than may have extention lag.

22. Thompson quadricepsplasty
 Result –
 variable amount of return of knee flexion
 Extensor lag has been reported to be as high as
67%.
 affect the stability of the knee
 some patients may require continuous bracing.
 extensor lag more if flexion attained on the
operation table 90-100 degrees.

23. Chang Gung Med J. 2007 May-Jun;30(3):263-9. Modified
Thompson quadricepsplasty to treat extension contracture of the
knee after surgical treatment of patellar fractures. Huang YC,
 N- 28
 extension contractures , surgical treatment of
patellar fractures
 FU = 2 years
 arc of motion improved from 72 degrees to 123
degrees (p < 0.001).
 no significant surgical complications.
 CONCLUSION: This surgical technique has a
high success rate with few complications.

24. J Bone Joint Surg Br. 2000 Sep;82(7):992-5. A modified
Thompson quadricepsplasty for the stiff knee. Hahn SB
 1987 -1997
 modified Thompson quadricepsplasty
 N = 20 stiff knees
 mean FU of 35 months (24 to 52).
 mean active flexion was 113.5 degrees (75 to 150).
 mean final gain in movement was 67.6 degrees (5 to 105).
 deep infection - 1
 The modified Thompson quadricepsplasty with
appropriate postoperative care can give good results.

25. Modified quadricepsplasty
 Skin incision – medial and lateral parapatellar incision
and anterolateral incision
 Step wise release – first medial and lateral retinaculae
and adhesion in suprapatellar, femoral condyle and
intraarticular
 If no adequate gain in ROM
 Anterolateral or lateral incision to release adhesion
around quadriceps muscles.

27. The Judet Quadricepsplasty:
 Judet (1959)
 technique using principal of muscle disinsertion
and sliding
 minimises damage to quadriceps mechanism
 Advantages - a controlled, sequential release of
the intrinsic and then the extrinsic components
which are limiting the knee flexion
 It reduces potential for iatrogenic quadriceps
rupture or extension lag.

28. Surgical Procedure:-
 two incisions:
 short medial parapatellar incision
 The medial retinaculum suprapatellar pouch and
intra articular adhesions are released through this
incision. The suprapatellar pouch is mobilized.
 long lateral incision

29. Surgical Procedure:-
 Patella and lateral retinacular tissues are freed ensuring
that patella may be easily lifted off the femoral candyles.
 The vastus lateralis is completely released from the linea
aspera and from the greater trochanter.
 The vastus intermedius lifted extra periosteally from
lateral and anterior surfaces of femur.
 The vastus medialis is not disturbed
 If necessary the rectus femoris is released from its iliac
origin.
 Meticulous haemostasis is achieved, suction drains are
inserted and only skin is closed.

30.  Advantages-
controlled and
sequential release of
components limiting
knee flexion
 Theoretically reduces
the potential for
iatrogenic extention
lag.

31.  West Indian Med J. 2005 Sep;54(4):238-41. Judet quadricepsplasty for
extension contracture of the knee. Rose RE.
 Knee. 2006 Aug;13(4):280-3. Epub 2006 May 2. Modified Judet's
quadricepsplasty for loss of knee flexion. Alici T et.al.
 Clin Orthop Relat Res. 2003 Oct;(415):214-20. Judet's quadricepsplasty,
surgical technique, and results in limb reconstruction. Ali AM et.al.
 mean pre-operative knee flexion - 30 degrees
 final follow-up to 100 degrees
 Advantage –
 no iatrogenic quadriceps rupture or extension
lag
 involves less soft tissue dissection
 less blood loss.

32. Postoperative treatment
 same for both Quadricepsplasty.
 immobilization after surgery -50 degree less than the
maximal flexion obtained at surgery.
 maintained for 2 to 3 days
 CPM until 90deg of passive flexion achieved.
 The Thomas knee splint with Pearsons attachment is
useful
 Passive and active exercises for quadriceps and
hamstrings
 is exercised during the day with active and active assisted
exercises.

33.  Arch Orthop Trauma Surg. 1986;104(6):346-51.
 Continuous passive motion after knee-joint arthrolysis
under catheter peridural anesthesia.
 Ulrich C, Burri C, Wörsdörfer O.
 Adequate analgesia by continuous anesthesia via a
peridural catheter; in combination with continuous
passive motion,
 N=22
 improvement ROM - 39 degrees to 120 degrees.
 Gain depends – not on severity of contracture but
on --
 etiology of the stiffness is more important.

34. JOT -2010
10 pts of metaphyseal fractures over 7 yrs period
Step one – removal of intraarticular obstacles
Step two - removal of extraarticular obstacle
Step three- gradual distraction by ilizarov fixator

35. Step 2 – release
extraarticular
Obstacles
VM,VI and VL
released
Step 1- remove
intraarticular obstacles
By lateral or medial
incisions

36. Distract the joint
Than achieve flexion
Obviates the disadvantages
Extensor lag
Wound problem
Rebound phenomennon of ilizarov

37. J Bone Joint Surg Am. 2007 Mar;89 Suppl 2 Pt.1:93-102. A new
treatment strategy for severe arthrofibrosis of the knee.
Surgical technique. Wang JH, Zhao JZ, He YH.
 extra-articular mini-invasive quadricepsplasty and subsequent intra-
articular arthroscopic lysis of adhesions
 1998 to 2001,
 N=22 severely arthrofibrotic knees.
 The mean age - 37 years.
 mean duration of follow-up 44 mos
 RESULTS: flexion increased from 27 degrees to 115 degrees excellent
(16) , good (5), and fair (1).
 superficial wound infection - one.
 persistent 15 degrees extension lag in one.
 CONCLUSIONS: This mini-invasive operation for the severely
arthrofibrotic knee can be used to increase the range of motion and
enhance functional outcome.

38. •First stage – release of lateral
patellar retinaculae
•Percutaneous parapatellar
lateral arthrotomy
•Release lateral retinaculae
fromlateral condyle of femur
•VL and ilio tibial band freed
• from distal femur

39. Stage two - mobilize suprapatellar pouch ,
PF compartment, anterior interval
i.e. posterior to infrapatellar fat pad and
anterior superior part of tibial plateau

40. Stage three- medial parapatellar
release – med patellar retinaculae, PF
and anterior interval

41.  Fourth stage – transect VI at musculo-tendinous
junction
fifth stage – lengthening of quadriceps tendon
Usually 90 degrees are gained
But gives enough space for
arthroscopic intraarticular release

42. Keep on manipulating in between the procedure
Closed suction drain
Post op management-
IV mannitol
Compressive dressing
Physical therapy

43. Arthroscopy assisted Quadricepsplasty:
 to reduce the morbidity of traditional Quadricepsplasty .
 initial extaarticular mini invasive Quadricepsplasty
 followed by intraarticular arthrocopic lysis of adhesions
 a gentle manipulation after the release.
 Sprague - mean gain of flexion of 28 degrees and improvement of
extension of 6 degrees after arthroscopic procedures.
 Arthroscopic methods are more successful in increasing flexion than
in increasing extension.
 ideal time to perform the operation is with in the first 9 months after
injury.
 The best results were obtained in 7 months.
 The results detoriated notably after one year.
 The age of the patient does not affect the end result.

44. N=19
post trauma stiffness combined intra- and extra- articular aetiology
release- infrapatellar, suprapatellar and gutter adhesions,
extra-articular proximal adhesions
Mean active flexion ( 1 Yr FU) 27.3 degrees to 119.3 degrees
Mean extension lag from 6 degrees to 1 degrees
No CPM daily PT
Overall patient satisfaction was excellent;
Arthroscopic aided quadriceps adhesion release is a good option

45. Arthroscopy. 1993;9(6):685-90. Stiffness of the
knee--mixed arthroscopic and subcutaneous
technique: results of 67 cases.
 . mixed-cause stiffness of the knee: intraarticular and
extraarticular.
 N= 67
 cause of stiffness - mostly ligamentous surgery, (76%).
 Preoperative ROM - 11 deg ex and 89 deg flex.
 arthroscopic arthrolysis
 Outcome generally excellent.

46. Conclusions
 Causes
 Manipulation
 Quadricepsplasty
 Post surgery protocols
 Arthroscopy assisted or minimally invasive
procedures

47. Thanks very much indeed for
patient hearing

48. Thank you very much for patient hearing

49. Am J Sports Med. 1987 Jul-Aug;15(4):331-41.
Infrapatellar contracture syndrome.
 infrequently recognized cause of posttraumatic knee morbidity.
 combination of restricted knee extension and flexion associated with patella entrapment.
 occur primarily as an exaggerated pathologic fibrous hyperplasia of the anterior soft tissues of the
knee beyond that associated with normal healing.
 secondarily to prolonged immobility and lack of extension associated with knee surgery, particularly
intraarticular ACL reconstruction. IPCS follows a predictable natural history which is
 divided into three stages. Symptoms, diagnostic findings, and recommended treatment are
determined by the stage at presentation.
 best treated by an anterior intraarticular and extraarticular capsular debridement and release,
followed by extensive rehabilitation.
 28 consecutive cases .
 At followup 3 months to 4 years postoperation, the patients had averaged 2.3 additional surgical
procedures following their index procedure or injury. The average increase in extension at followup
was 12 degrees with the average increase flexion 35 degrees.
 Eighty percent of patients demonstrated signs and symptoms consistent with patellofemoral
arthrosis;
 16% of the patients demonstrated patella infera.
 prevention or early detection and aggressive treatment are the only ways of avoiding complication in
these problem cases.

50. Plast Reconstr Surg. 2007 Jan;119(1):203-10. The advantages of
free tissue transfer in the treatment of posttraumatic stiff knee.
Ulusal AE, et.al
 Open fractures of the distal femur involving the joint, surrounding ligament,
and soft tissues are among the worst types of injuries that may eventually lead
to stiff knee.
 Release procedures + simultaneously applied free flaps
 N- 9 with posttraumatic severe stiff knees
 All patients underwent release procedures,
 In addition, free tissue transfers were performed at the same stage as the
release procedures to cover the resultant soft-tissue defects or carried out at a
secondary stage because of wound-healing problems.
 The mean follow-up period was 38 months.
 RESULTS: Complete flap survival was 100 percent.
 no infection or wound-healing problems
 CONCLUSION: Surgical reconstruction with the use of free flaps to cover
soft-tissue defects, providing remarkable advantages for postoperative
rehabilitation.

51.  J Pediatr Orthop B. 2005 May;14(3):219-24. Quadricepsplasty in arthrogryposis
(amyoplasia): long-term follow-up. Fucs PM, Svartman C, de Assumpção
RM, Lima Verde SR. Orthopaedic Department, Santa Casa Medical School and
Hospitals, Pavilhão 'Fernandinho Simonsen', São Paulo, Brazil. Eight
patients with arthrogryposis multiplex congenita (amyoplasia type) (11 knees)
with knee hyperextension deformity underwent quadricepsplasty and were
analyzed during an average follow-up period of 11 years and 2 months. The
results were clinically analyzed based on gait pattern, range of movement, and
orthotic requirements. Joint congruency was evaluated by radiography
according to the Leveuf Pais classification. A satisfactory result was the
correction of the deformity, articular congruency, sufficient range of
movement, adequate gait pattern and no need for orthosis. A satisfactory
outcome occurred in five of the eight patients (eight knees). We considered
an unsatisfactory result when any of these conditions occurred. Our
experience demonstrated that the quadricepsplasty corrected the
hyperextension deformity of the knee joint, improved function, gait pattern,
and maintained the muscle power of the quadriceps.

52. J Pediatr Orthop B. 2004 Jul;13(4):254-8. Treatment of
severe iatrogenic quadriceps retraction in children.
 severe iatrogenic infantile quadriceps retraction
 two different surgical techniques of quadricepsplasty:
 Judet technique
 other based on Thompson techniques.
 N= 76 FU 3 years -
 maximal knee flexion
 average of -3 to 81 degree in the first group
 37 to 115 degree in the second group.
 The most frequent complications - skin necrosis after the
Judet quadricepsplasty and active extension lag after the
Thompson procedure.

53. J Bone Joint Surg Br. 2003 Mar;85(2):261-4. Quadricepsplasty
for knee stiffness after femoral lengthening in congenital short
femur.
 N- 5 children
 stiffness of the knee after femoral lengthening for congenital short
femur using an Ilizarov external fixator
 Unifocal lengthening distal metaphysiodiaphyseal region -mean gain
of 6.5 cm.
 mean percentage lengthening was 24%. At the end of one year after
removal of the Ilizarov frame and despite intensive physiotherapy all
patients had stiffness.
 Physiotherapy was continued after the quadricepsplasty and, at the
latest follow-up (mean 27 months),
 the mean active flexion was 102 degrees (80 to 130).
 The gain in movement ranged from 50 degrees to 100 degrees..
Quadricepsplasty is a useful procedure for stiffness of the knee after
femoral lengthening which has not responded to physiotherapy.

54.  Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 1999 Nov;13(6):355-8. [Application of sartorius muscle
in the quadricepsplasty] [Article in Chinese] Chen QS, Zhu LX, Chen X. Department of Orthopedic
Surgery, Zhujiang Hospital, First Military Medical University, Guangzhou, Guangdong, P. R. China,
510282. OBJECTIVE: Extension stiffness of knee joint is always treated by the quadricepsplasty, but
the main deficiency of this method is that patient feels weakness of lower limb and easily kneels
down. The aim of this article is to explore the method to resolve the complications after
quadricepsplasty. METHODS: Since 1978 to 1997, on the basis of traditional procedures of
quadricepsplasty, sartorius muscle was used to reinforce the extension of knee joint. The lower 2/3 of
sartorius muscle was fully dissociated only with its insertion intact. A tendon-periosteal-bone flap,
about 2 cm in width, was managed on the anterior surface of patella, with its pedicle on the medial
edge of patella. The tendon-periosteal-bone flap was used to fix the dissociated sartorious into
patella to reinforce the extension of knee joint. The very lower part of sartorius was mainly
aponeurosis, with the help of an aponeurosis bundle of iliotibial tract, it was fixed into the insertion
of patellar ligament, through a bony tunnel chiseled adjacent to the insertion of patellar ligament. By
now the movement of knee joint extension was strengthened by the transferred sartorius muscle.
Postoperatively, every patient was required to extend and flex knee joint actively and/or passively.
Altogether 12 patients were treated, 9 of them were followed up with an average of 14 months.
RESULTS: The average movement was increased from 15 degrees to 102 degrees, and the average
myodynamia was improved from grade II to grade IV. CONCLUSION: Traditional quadricepsplasty
co-operated with transfer of sartorius muscle can strengthen the myodynamia of knee joint
extension. It is simple method and can really achieve good function.

55.  Arthroscopy. 2001 May;17(5):504-9. Endoscopic quadricepsplasty: A new surgical technique. Blanco
CE, Leon HO, Guthrie TB. Orthopaedic Division, Hospital Hermanos Ameijeiras, Havana, Cuba. We
present a new surgical subperiosteal endoscopic technique for the release of fibrosis of the
quadriceps to the femur caused by gunshot injuries, postsurgical scarring, and fractures, that was
developed at the Arthroscopy Group at Hospital Hermanos Ameijeiras in Havana, Cuba. The
technique used is a proximal endoscopic subperiosteal extension of the usual arthroscopic intra-
articular release of adhesions, using periosteal elevators and arthroscopic scissors placed through
medial and lateral superior knee portals to release adhesions and bands of scar tissue beneath the
quadriceps mechanism. The technique was used in a prospective case series of 26 male patients aged
19 to 22 years between February 1997 and March 1998 who presented with clinically and
ultrasonically documented extra-articular fibrosis resulting in ankylosis of the knee in extension.
Only patients who had reached a plateau in their aggressive physiotherapy program with no further
progression in knee flexion for 3 months were selected. Those with joint instability, motion-limiting
articular surface pathology, and muscle or neurologic injury were excluded. All patients had
obtained satisfactory results at 2-year follow-up. The extra-articular release gained at final follow-up
was between 30 degrees and 90 degrees of flexion in addition to that obtained at the completion of
the standard intra-articular release. Complications included 1 case of deep vein thrombosis, 2 cases
of scrotal edema, 5 cases of hemarthrosis, and 2 cases of reflex sympathetic dystrophy. We have
found this technique useful in obtaining additional flexion and improved function in a difficult class
of patients with ankylosis caused by extra-articular fibrosis of the quadriceps to the femur, allowing
immediate aggressive rehabilitation and presenting a useful outpatient alternative with fewer and
less severe complications than described with the classic open Thompson's quadricepsplasty.

56. Mil Med. 2000 Apr;165(4):263-7.
Quadricepsplasty after war fractures.
 fractures by explosive devices, intra-articular
fractures of the knee,
 N=10 .
 were treated by the external fixation method
 manifested markedly decreased knee flexion
(15-70 degrees, with an average of 32 degrees).
 After quadricepsplasty and physical therapy,
 the achieved knee flexion was enough for normal
walking (80-130 degrees, average 97.5 degrees).
 Mean knee mobility was increased 65.5 degrees..

57. Arthroscopy. 1998 Mar;14(2):212-4. Arthroscopically assisted
percutaneous quadricepsplasty: a case report and description
of a new technique.
 . To our knowledge an arthroscopically assisted
method of performing a quadricepsplasty has not
been previously described. We present such a case
and the details of the arthroscopically assisted
method that may provide an alternative, minimally
invasive means of restoring knee flexion in the setting
of a post-traumatic extension contracture.

58. Acta Orthop Belg. 1996 Jun;62(2):79-82. The Judet
quadricepsplasty: a retrospective analysis of 16 cases.
 severe extension contractures of the knee - 16
Preoperatively = average of 23 degrees flexion. 30
degrees flexion preoperatively = 2.
 average improvement in knee flexion - 69 deg
 11 (68.7%) patients achieving a final flexion of 90
degrees or more.
 15 degrees loss of terminal active extension - 4.
rapid recurrence of the contracture – 1
 a deep infection 1
 acute compartment syndrome - 1.

59. Injury. 1993 Feb;24(2):104-8. Quadricepsplasty following
femoral shaft fractures.
 12 quadricepsplasties performed on 10 patients with
stiff knees following united femoral shaft fractures .
 multiple operations and delayed union. The increased
range of flexion achieved in this series is higher than
in those reported previously.

60.  Z Orthop Ihre Grenzgeb. 1982 May-Jun;120(3):250-8. [Results of knee joint
arthrolysis surgery (author's transl)] [Article in German] Blauth W,
Hassenpflug J. This work reports the results of operative treatment of knee-
stiffness from 1973-1981 in the Department of Orthopaedic Surgery, University
Kiel. 42 out of 46 occurrences of age, were post-operatively controlled. In
most cases the stiffness was of traumatic origin. In more than one half of the
cases the pre-operative controlled. In most cases the stiffness was of traumatic
origin. In more than half of the cases the pre-operative degree of motion was
less than 60 degrees. Intraarticular revision alone or extraarticular revision
alone or a combination of both and other bone surgery was performed in
approximately 1/4 of the patients respectively. The absolute range of motion,
an average of 58 degrees pre-operatively, improved to 114 degrees post-
operatively. The mean relative improvement of motion, in regard to a norm of
140-0-0 degrees, was 68% at discharge. Among our patients complication were
seldom. In our opinion operative arthrolysis in indicated cases is a tried and
proven method for treatment of stiff knees.

61. Knee contrcture in extension
 Adhesions - single common factor .
 in synovial cavity, especially is supra patellar
pouch,
 in capsular and periarticular tissue,
 between quadriceps and the femur
 and fascia latae and the femur.
 Vastus intermedius most commonly affected
by fibrosis. Adhesions of rectus femoris/ vastus
medialis are rare whole quadriceps mass may
be involved.

62. Knee. 2006 Aug;13(4):280-3. Epub 2006 May 2. Modified
Judet's quadricepsplasty for loss of knee flexion. Alici T et.al.
 N=11
 average follow-up of 49 months
 mean pre-operative knee flexion - 30 degrees
 final follow-up to 100 degrees
 extension lag –no .
 excellent (3) , good ( 7)
 useful procedure to correct the disabling flexion
loss in the knee.

63. West Indian Med J. 2005 Sep;54(4):238-41. Judet quadricepsplasty
for extension contracture of the knee. Rose RE.
Thompson quadricepsplasty - variable return of
knee flexion and possibility of significant
extension lag.
Judet quadricepsplasty –
controlled, sequential release of the intrinsic and
extrinsic components limiting knee flexion
reduced potential for iatrogenic quadriceps rupture
or extension lag. The modified Judet
quadricepsplasty has definite advantages over the
Judet technique since it usually involves less soft
tissue dissection and consequently less blood loss.

64. Clin Orthop Relat Res. 2003 Oct;(415):214-20. Judet's
quadricepsplasty, surgical technique, and results in limb
reconstruction. Ali AM et.al.
 Judet's technique - potential advantages
 less damaging to the quadriceps mechanism
 addresses external fixator pin site tethering on lateral side
 n- 10 consecutive patients
 treated with EF
 minimal followup of 20 months.
 flexion of 33 degrees to 105 degrees in OT and to 88 degrees on final .
 one fair, seven good, and two excellent results.
 postoperative complications, one hematoma and one infection.
extension lag (10 degrees ) developed in one patient.
 Judet quadricepsplasty successfully increases flexion range with
minimum impairment of quadriceps function.

65. Surgical Procedure:-
 An arthroscopic sheath and blunt trocar are inserted through standard anteromedial
and anterolateral portals. The blunt trocar is carefully passed beneath the patella and
suprapatellar pouch. The trocar is used to bluntly disrupt any adhesion in suprapatellar
pouch and in both medial and lateral gutters. If adhesions are dense, patellofemoral
joint usually is spared. The debridement is started in peripatellar region and extended
outwards. Once the suprapatellar pouch has been restored, an inflow canula is inserted
through a superior portal. The dissection is continued down into the medial and lateral
gutters and compartments and finally into the intercondylar area. Occasionally
proliferation of fibrous tissue is present within the intercondylar notch and anterior
regions; this should be removed because it may limit the extension. Some investigators
recommended a lateral retinacular release as part of the procedure if patellar mobility is
restricted after the arthroscopic release. After the systemic lysis of adhesions, a gentle
manipulation is performed. A bulky compressive dressing is applied.
 It is helpful to perform this procedure with the patient under a continuous epidural
anesthesia, which is maintained for 2 to 3 days after surgery. The patient is placed on a
continuous passive motion immediately after surgery. The suction drain is removed
after 2 days

71. Knee contrcture in extension
 Fibrosis of vastus intermedius muscle, scarring
down to the rectus femoris to the femur in
suprapatellar pouch and proximally.
 Adhesions between the patella and the femoral
condyles.
 Fibrosis and shortening of lateral expansions of
vasti and their adherence to the femoral
condyles.
 Actual shortening of rectus femoris muscle.

73. J Knee Surg. 2008 Jan;21(1):39-42. A conservative
approach to quadricepsplasty: description of a
modified surgical technique and a report of three
cases. Hussein R et.al.
 Various techniques ,large exposures, a permanent
extensor lag.
 technique with limited exposure,
 principles remain the same